Provider Demographics
NPI:1639192446
Name:JOHNSON, JAIME ANN (PA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 S WALKER AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9475
Mailing Address - Country:US
Mailing Address - Phone:405-632-4468
Mailing Address - Fax:405-632-0436
Practice Address - Street 1:2506 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804
Practice Address - Country:US
Practice Address - Phone:405-395-9050
Practice Address - Fax:405-395-9630
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1198363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1198OtherMEDICAL LICENSE
OK242703701Medicare PIN